Professional Nursing Practice within Nursing Care Models The American Nurses Association (2010) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (66). The American Organization of Nurse Executives (AONE) assumptions for future patient care delivery include the following: Assumption 1: The role of nurse leaders in future patient care delivery systems will continue to require a systems approach with all disciplines involved in the process and outcome models. Assumption 2: Accountable Care Organizations will emerge and expand as key defining and differentiating healthcare reform provisions that will impact differing care delivery venues. Assumption 3: Patient safety, experience improvement and quality outcomes will remain a public, payer and regulatory focus driving work flow process and care delivery system changes as demanded by the increasingly informed public. Assumption 4: Healthcare leaders will have knowledge of funding sources and will be able to strategically and operationally deploy those funds to achieve desired outcomes of improved quality, efficiency, and transparency. Assumption 5: The joint education of nurses, physicians, and other health professionals will become the norm in academia and practice promoting shared knowledge that enables safer patient care and enhancing the opportunity for pass-through dollars to apply to APRN residencies and/or related clinical education (2010, pp. 1–3). The five NAM core competencies are interrelated with these assumptions. Also, all of these elements have been discussed in earlier chapters or will be discussed in later chapters, as they are critical aspects of leadership and management. Intertwined within these critical elements is the recognition of the importance of leadership, autonomy, responsibility, delegation, and accountability. Autonomy, which focuses on an individual’s ability to make decisions, requires competence and skills that focus on the nurse–patient relationship. It also means that there needs to be an organized assessment method to determine patient care needs and reassigning staff. Nurses also have the right to consult with others as professionals when they provide or manage care. Autonomy, control, and decision making are related, and state Nurse Practice Acts reflect on nurse autonomy. Nurses who feel that they have autonomy know that they have the right to make decisions in their daily practice and also actively participate in developing organizational policy and change. Staff autonomy, however, does not work in organizations in which leaders are authoritarian and when centralized decision making and control are key characteristics of the organization. This situation will quickly lead to conflict. In addition, the work environment must be .

1. Professional Nursing Practice within Nursing Care Models
The American Nurses Association (2010) defines nursing as
“the protection, promotion, and optimization of health and
abilities, prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families,
communities, and populations” (66). The American
Organization of Nurse Executives (AONE) assumptions for
future patient care delivery include the following: Assumption
1: The role of nurse leaders in future patient care delivery
systems will continue to require a systems approach with all
disciplines involved in the process and outcome models.
Assumption 2: Accountable Care Organizations will emerge and
expand as key defining and differentiating healthcare reform
provisions that will impact differing care delivery venues.
Assumption 3: Patient safety, experience improvement and
quality outcomes will remain a public, payer and regulatory
focus driving work flow process and care delivery system
changes as demanded by the increasingly informed public.
Assumption 4: Healthcare leaders will have knowledge of
funding sources and will be able to strategically and
operationally deploy those funds to achieve desired outcomes of
improved quality, efficiency, and transparency. Assumption 5:
The joint education of nurses, physicians, and other health
professionals will become the norm in academia and practice
promoting shared knowledge that enables safer patient care and
enhancing the opportunity for pass-through dollars to apply to
APRN residencies and/or related clinical education (2010, pp.
1–3). The five NAM core competencies are interrelated with
these assumptions. Also, all of these elements have been
discussed in earlier chapters or will be discussed in later
chapters, as they are critical aspects of leadership and
management. Intertwined within these critical elements is the

2. recognition of the importance of leadership, autonomy,
responsibility, delegation, and accountability. Autonomy, which
focuses on an individual’s ability to make decisions, requires
competence and skills that focus on the nurse–patient
relationship. It also means that there needs to be an organized
assessment method to determine patient care needs and
reassigning staff. Nurses also have the right to consult with
others as professionals when they provide or manage care.
Autonomy, control, and decision making are related, and state
Nurse Practice Acts reflect on nurse autonomy. Nurses who feel
that they have autonomy know that they have the right to make
decisions in their daily practice and also actively participate in
developing organizational policy and change. Staff autonomy,
however, does not work in organizations in which leaders are
authoritarian and when centralized decision making and control
are key characteristics of the organization. This situation will
quickly lead to conflict. In addition, the work environment must
be conducive to collaboration with physicians and all relevant
staff, as is discussed in Chapter 13. A nursing practice model
that does not address responsibility will not be effective. Along
with this is the need to clearly recognize the importance of
delegation. Delegation is discussed in more detail in Chapter
15. Accountability is a term that is typically found in job
descriptions and descriptions of organizational structure. “It is
related to answerability and to responsibility—judgment and
action on the part of the nurse for which the nurse is answerable
to self and others for those judgments and actions” (Fowler,
2015, p. 44). “Responsibility refers to the specific
accountability or liability associated with the performance of
duties of a particular nursing role and may, at times, be shared
in the sense that a portion of responsibility may be seen as
belonging to another who was involved in the situation”
(Fowler, 2015, p. 44). Nurses need to know that when they
provide patient care, their work has relevance—it must reach
outcomes. Accountability, autonomy, and responsibility need to
be considered when nursing practice models are assessed.

3. Nursing models of care are developed to support or enhance
professional practice, and by considering these elements and
characteristics, the models will be more effective. Within an
HCO, how do nurses provide nursing care? What is a model of
care? Are these elements found in the model? Models might also
be called nursing or patient care delivery systems. These models
have undergone major changes over the past several decades.
Nursing practice models have been used to implement resource-
intensive strategies with the goal of decreasing expenses and
using staff more effectively. Nursing models help to identify
and describe nursing care. The NAM emphasis on the five core
competencies could also be used for a model, and as newer
models are discussed later, it is easy to see how these five
competencies are the key elements of healthcare delivery.
Historical Perspective of Nursing Models
The following is a description of common models, some of
which have undergone many changes over the years or are not
used anymore, but they have had an impact on newer models.
TotalPatient Care/Case Method
In this model, which is the oldest, the registered nurse is
responsible for all of the care provided to a patient for a shift. A
major disadvantage of this model is the lack of consistency and
coordinated care when care is provided in eight-hour segments.
This type of care is rarely provided today, except among student
nurses who are assigned to provide all of the care for a patient
during the hours that they are in clinical. Even in this case, the
students frequently do not provide all of the care as they may
not be qualified to do this, and a staff nurse maintains overall
responsibility for the care. Home health agencies use a form of
this model when nurses are assigned patients and provide all the
required home care; however, even this has been adapted as
teams provide more home care. An RN may coordinate the care
and provide professional nursing services, but a home care aide
may provide most of the direct care, and other providers such as

4. a physical therapist, dietician, and social worker may be
required for specialty care.
Functional Nursing
The model of functional nursing is a task-oriented approach,
focusing on jobs to be done. When it was more commonly used,
it was thought to be more efficient. The nurse in charge
assigned the tasks (e.g., one nurse may administer medications
for all or some of the patients on a unit; an aide may take vital
signs for all patients). A disadvantage of this model is the risk
of fragmented care. In addition, this type of model also leads to
greater staff dissatisfaction with staff feeling they are just
grinding out tasks. When different staff members provide care
without awareness of other needs and the care provided by
others, individualized care may also be compromised. This
model is not used much now. It can be found in some long-term
care facilities and in some behavioral/psychiatric inpatient
services, although in a modified form. In the latter situation, a
registered nurse may be assigned the task of medication
administration for the unit, and psychiatric support staff may be
assigned such tasks as vital signs and safety checks of all
patients. In this situation, RNs would still be assigned to
individual patients to coordinate their care.
Team Nursing
This model was developed after World War II during a severe
nursing shortage and other major changes in medical technology
occurred. It replaced functional nursing. A nursing team
consists of a registered nurse, licensed practical/vocational
nurses, and UAP. This team of two or three staff provides total
care for a group of patients during an 8- or 12-hour shift. The
RN team leader coordinates this care. In this model the RN has
a high level of autonomy and assumes the centralized decision-
making authority. Although the past approach to team nursing
was thought to use decentralized decision making with decisions
made closer to the patient, there actually was limited team

5. member collaboration. In addition, these teams tended to
communicate only among themselves and not as well with
physicians and other healthcare providers. The team concept or
model also focused on tasks rather than patient care as a whole.
More current versions of the team model are different from this
earlier type. Currently the team model has been changed to meet
shifts in organizations and leadership corresponding to the
needs for better consistency and continuity of care as well as
collaboration and coordination and patient-centered care.
Primary Nursing
In the late 1970s, care became more complex, and nurses were
dissatisfied with team nursing. In the primary nursing model,
the primary nurse, who must be an RN, provides direct care for
the patient and the family; an associate nurse provides care
following the care plan developed by the primary nurse when
the primary nurse is not working and assists when the primary
nurse is working. The primary nurse needs to be knowledgeable
about assigned patients and must maintain a high level of
clinical autonomy. When primary nursing was first used, it was
easier to substitute RNs for other healthcare providers as cost
was not as much of a focus as it is today. Over time the nursing
shortage changed and salaries increased. Implementing primary
nursing then became more difficult, and healthcare cost moved
to the top of the concerns. Primary nursing is often viewed as a
model in which the primary nurse has to do everything, limiting
collaborative or team efforts, although it does not have to be
implemented in this way. Second-generation primary nursing
clarified some of the issues about this practice model. One of
the critical problems with primary nursing was whether or not it
required an all-RN staff, which was thought to increase staff
costs. The second-generation view of primary nursing noted that
the mix of staff was more important than having an all-RN staff.
Another concern with primary nursing was a need to develop a
clear definition of 24-hour accountability, which was
interpreted by some as 24-hour availability. This, of course, is
not a reasonable approach, and it really does not apply to

6. primary nursing. When the primary nurse is not working, the
associate nurse provides the care. Primary nursing is a
responsibility relationship between the nurse and the patient.
The primary nurse is not the only caregiver but does have
responsibility for planning nursing care and ensuring that care
outcomes are met. Only registered nurses can be primary nurses.
This role and the model require RNs who are competent and
possess leadership skills. Primary nursing is not used as much
today.
Care and Service Team Models
In the 1980s care and service team models began to replace
primary nursing. These models are implemented differently in
different hospitals, as is true of most of the models. Key
elements of these models are empowered staff, interprofessional
collaboration, skilled workers, and a case management approach
to patient care—all elements related to the more current views
of leadership and management (IOM, 2011). Care and service
teams introduced the different categories of assistive personnel
(e.g., multiskilled workers, nurse extenders, and UAP). There
has been some disagreement as to whether these new staff
member roles were complementary or involve the substitution of
professional nursing care.
Complementary Models
Complementary models began in 1988 by using nurse extenders,
such as a unit assistant, who would be responsible for
environmental functions. The nurse would then have more time
for direct patient care. Does this reduce costs? When nurse
positions are changed to nurse extender positions, there is some
cost reduction, but this change can impact all nursing staff.
Complementary models are not used as much today and have
been replaced by substitution models in HCOs. Substitution
models tend to use multiskilled technicians to perform select

7. nursing activities, and the RNs supervise these activities.
Another approach is cross-training. This involves training staff
to work in different specialty areas or to perform different
tasks. For example, a respiratory therapist may be trained not
only to perform typical respiratory therapist tasks but also
phlebotomy and basic nursing care. This offers much more
flexibility in that staff can fulfill many different needs. They
can then be used, as staffing adjustments are needed for changes
in patient census or acuity. It is critical that this cross-training
meet patient needs so staff will be able to deliver quality, safe
care and not feel undue stress while delivering the care. It is
also important that state practice act requirements are met, and
this is not always easy to accomplish. It requires HCO
education staff to provide support, ongoing educational training,
and documentation of competencies, as well as management
staff that understand which staff members are qualified to move
from area to area. Hospitals and other HCOs have tried to find
the best methods for using substitution without compromising
quality and safety and yet control costs. As demands change,
different models will be required, and nursing leadership to
develop these models will be critical.
Case Management Model
As with earlier team models, the RN must spend time
coordinating care and the work. The focus of the team is on
patient-centered care as opposed to the nurse–patient
relationship. The case management model is based on the
assumption that patients with complex health problems,
catastrophic health situations, and high-cost medical conditions
need assistance in using the healthcare system effectively, and a
case manager can help patients with these needs (Finkelman,
2011). Case managers may also work with the teams to achieve
outcomes, which increases shared accountability. Case
management can be viewed as a nursing model when the case
manager is a nurse; however, in some HCOs nurses are not used

8. as case managers but rather other healthcare professionals such
as social workers serve as case managers. Several healthcare
professional organizations and experts have defined case
management; however, there clearly is no universally accepted
definition for case management. Case management is used in
many different types of settings, and the setting also affects the
definition. Examples of
Newer Nursing Models Interprofessional Practice Model
The interprofessional practice model is emphasized in the IOM
reports on quality improvement by identifying the importance of
all health professions meeting the interdisciplinary or
interprofessional competency and emphasizing the need to work
in interprofessional teams “to cooperate, collaborate,
communicate, and integrate care in teams to ensure that care is
continuous and reliable” (2003, p. 4). These teams include
providers from different healthcare professions and occupations
designed to meet the required patient needs. With increasing
complex patient care needs, this model is better able to address
needs and to effectively use a mix of expertise and knowledge
to reach patient outcomes. Patient-centered care is the focus.
Synergy Model for Patient Care™
This model of care was developed by the American Association
of Critical-Care Nurses, but it has been applied in all types of
nursing units. The model recognizes the need to match the
nurse’s competence with the patient’s characteristics, needs,
and the clinical unit (American Association of Critical-Care
Nurses, 2014). Patient characteristics incorporated into this
model are as follows (American Association of Critical-Care
Nurses, 2014): Resiliency: the capacity to return to a restorative
level of functioning using compensatory/coping mechanisms;
the ability to bounce back quickly after an insult Vulnerability:

9. susceptibility to actual or potential stressors that may adversely
affect patient outcomes Stability: the ability to maintain a
steady-state equilibrium Complexity: the intricate entanglement
of two or more systems (e.g., body, family, therapies) Resource
availability: extent of resources (e.g., technical, fiscal,
personal, psychological, and social) the
patient/family/community brings to the situation Participation
in care: extent to which patient/family engages in aspects of
care Participation in decision making: extent to which
patient/family engages in decision making Predictability: a
characteristic that allows one to expect a certain course of
events or course of illness The Synergy model ties the above
patient characteristics with the following nurse competencies
(American Association of Critical-Care Nurses, 2014): Clinical
judgment: clinical reasoning, which includes clinical decision
making, critical thinking, and a global grasp of the situation,
coupled with nursing skills acquired through a process of
integrating formal and informal experiential knowledge and
evidence-based guidelines. Advocacy and moral agency:
working on another’s behalf and representing the concerns of
the patient/family and nursing staff; serving as a moral agent in
identifying and helping to resolve ethical and clinical concerns
within and outside the clinical setting. Caring practices: nursing
activities that create a compassionate, supportive, and
therapeutic environment for patients and staff, with the aim of
promoting comfort and healing and preventing unnecessary
suffering. Includes, but is not limited to, vigilance, engagement,
and responsiveness of caregivers, including family and
healthcare personnel. Collaboration: working with others (e.g.,
patients, families, healthcare providers) in a way that
promotes/encourages each person’s contributions toward
achieving optimal/realistic patient/family goals. Involves intra-
and interprofessional work with colleagues and community.
Systems thinking: body of knowledge and tools that allow the
nurse to manage whatever environmental and system resources
exist for the patient/family and staff, within or across healthcare

10. and nonhealthcare systems. Response to diversity: the
sensitivity to recognize, appreciate, and incorporate differences
into the provision of care. Differences may include, but are not
limited to, cultural differences, spiritual beliefs, gender, race,
ethnicity, lifestyle, socioeconomic status, age, and values.
Facilitation of learning: the ability to facilitate learning for
patients/families, nursing staff, other members of the healthcare
team, and community. Includes both formal and informal
facilitation of learning. Clinical inquiry (innovator/evaluator):
the ongoing process of questioning and evaluating practice and
providing informed practice. Creating practice changes through
research use and experiential learning.
Patient Navigation
Patient navigation is a model that has primarily focused on
patients with cancer who are at risk for poor cancer outcomes
though other types of patient populations have also benefited
from patient navigation (Wells et al., 2008). Clinical nurse
leaders often hold the position of nurse navigator. Patient
navigation focuses on decreasing barriers to better ensure that
patients get the care they need when they need it (Finkelman,
2011). This model is “an intervention designed to reduce health
disparities by addressing specific barriers to obtaining timely,
quality healthcare” (Wells et al., 2008, p. 2010).
The ACA and New Models
The Future of Nursing (Institute of Medicine, 2011) includes
content about transformational models of nursing across
different care settings. The report notes there are some common
themes from the examples reviewed. “In order to meet the
challenges of the future, we must embrace technology, foster
partnerships, encourage collaboration across disciplines and
settings, ensure continuity of care and promote nurse-lead/nurse
managed health care” (402). The ANA has also commented on

11. the ACA and its potential impact on nursing models of care. The
ANA notes, as do other sources such as the NAM, that the
healthcare system is dysfunctional and fragmented. A major
goal of the ACA is to rebalance the healthcare system’s
resources by identifying several models of care, focusing on
primary care, that might help to reach this goal (2010):
Accountable Care Organization (ACO): Provides a collaborative
model for primary care providers and specialists who work
together to achieve quality care and control costs. ACOs that
are successful receive financial incentives. ACOs are part of the
Medicare Program. Providers may include MDs, APRNs, CNSs,
and PAs. Medical/Health Homes: The focus in this model is on
primary care providers coordinating patient care. Financial
incentives as well as interprofessional teams may also be part of
this model. Nurse-Managed Health Clinic (NMHC): This is a
clinic that is managed by nurses that provides comprehensive
primary care and wellness services and must be associated with
a university/college/department of nursing, a federally qualified
health center, or an independent nonprofit health or social
services agency. This type of clinic is led by APRNs.
Shared Governance and Empowerment
Shared governance is an approach to management that engages
staff at all levels in the decision-making process. This does not
mean that there are inactive or ineffective leaders and
managers, but rather they meet their management
responsibilities by ensuring that staff are active in the
processes, which increases each nurse’s influence over the
organization, empowering staff. Shared governance can be
viewed as a management philosophy, a professional practice
model, and an accountability model that focuses on staff
involvement in decision making, particularly in decisions that
affect their practice. In doing this, the model provides staff with
autonomy and control over implementation of their practice—

12. legitimizing control over their own practice. Nurses in these
organizations usually feel less powerless and are more efficient
and accountable. A critical factor in shared governance is that
accountability and responsibility are found in the same person.
Accountability should rest in the person who is most likely to
be the most effective person to complete the function. For
individual staff to be accountable and responsible for a function
or task, staff must also have the authority to make sure that the
right decisions are made. Transformational leadership enhances
shared governance. As was discussed in Chapter 1, an important
element of leadership is self-awareness, and it is essential in
shared governance. In this type of organizational arrangement,
staff members feel committed to the HCO and view themselves
Case Study Does a Nursing Model Make a Difference? You are
the director of staff development in a large university hospital,
and the chief nurse executive (CNE) has met with you to discuss
orientation for student nurses and faculty. The CNE is
concerned that students and faculty do not understand the
hospital’s new nursing model, Synergy Model for Patient
CareTM. She tells you it is your job to correct this problem.
You leave the meeting overwhelmed. This seems like a big
responsibility to you. The hospital has many nursing students
from three schools of nursing that use its services for
practicum. All have to attend a four-hour orientation to the
hospital, which is already overburdened with content, and the
faculty and students have limited time for orientation. The units
have also been struggling with applying the model since it was
initiated six months ago.
Questions
Why is it important for the students and faculty to understand
the model? How does the nursing model relate to the
organization’s theory or approach? How would you describe this
model? Consider methods and examples. Develop a plan that
you will submit to the CNE explaining how you will address

13. this problem. Whom might you include in developing the plan
and in implementing it? as partners in meeting the goals of the
HCO. In shared governance nurse managers typically are not
directly involved in daily direct patient care, although there are
some managers who are still involved in direct care. The typical
responsibilities of the nurse manager are staffing, program
evaluation, personnel evaluation, coordination, allocation of
resources, financial activities, and planning, as discussed in
Chapter 1. If patient care outcomes are not met, it is the
responsibility of the nurse providing the care to address this
issue. The nurse manager may become involved, but it is the
direct care provider who should take the lead. In other words,
clinical practice is the responsibility of the practitioners. When
clinical problems occur, the nurse who provides direct care
must be the one to solve these problems, working with the care
team. The main factor in shared governance is that decision
making is spread over a larger number of staff and is
decentralized. Nurses are accountable for not only their
management activities but also their practice. Healthcare
organizations that use shared governance must have clear
communication processes, or the organization will encounter
problems and confusion in the decision-making process. The
key components of shared governance are practice, quality,
education, and peer process/governance. How are these
accomplished? As with any such change, some organizations
actually change and others merely appear to change to this
model, but in the latter situation, very little has really changed
in the decision-making process or in actual practice. Shared
governance is associated with collaboration, horizontal
relationships, and investment, and these need to be
demonstrated in the organization. The change has to be real, and
typically when it is, staff are more satisfied. Organizations that
use this model require some type of structure that relates to the
shared accountability, such as councils, cabinets, committees, or
a combination of these groups or teams that make the decisions.
The chain of command is not the same as in traditional

14. organizations. In the shared governance model, these groups
make many of the decisions about policies, procedures, and
other aspects of getting the work done. How might shared
governance be implemented? Healthcare organizations have
been working for several years to create leaner and more
effective organizations. It is important to recognize that to
move toward a shared governance model, the organization must
take a comprehensive change approach and not an incremental
approach. All parts of the organization and all staff must be
expected to change. This is very difficult to accomplish, but if
shared governance is the goal, it is necessary. Decentralized
decision making is now found in many HCOs, and it is
frequently associated with participative management strategies
such as a shared governance model. This approach to
organizational structure and process is associated with the
economy, job satisfaction, and retention. For decentralization to
be effective, staff must have autonomy to make decisions. All
of this is intimately connected with shared governance. It
requires staff members who are committed to the organization’s
values and goals and demonstrate this by working to meet the
goals.